The gynecological examination — compromising position, cold speculum, occasional cringey swab — has been an integral and infamous part of women’s health care in some form since around the 19th century. Traditionally performed in healthy women as a screening tool for several conditions, like gynecologic cancer, infections, and pelvic inflammatory disease — the gynecological exam is undergoing an overhaul, based on new data on its effectiveness and women’s comfort.
The annual rite was finally questioned in 2012, when new guidelines from the American Cancer Society and other health associations suggested that a part of the exam called the Pap smear — a test for cervical cancer screening — should no longer be annual, but done in intervals of three to five years. That move sparked debate over another part of the exam: If a woman is not due for her Pap test, and not experiencing any symptoms of gynecological disease, should she still be subjected to a yearly pelvic exam?
The age-old routine
During a pelvic exam, a woman lies on her back on an examination table while wearing nothing but a hospital gown. She’s then asked to slide her buttocks to the edge of the table and place her feet in stirrups. With her knees bent and legs spread apart, the provider begins the visual component of the exam by observing the vulva, looking for rashes and lesions.
The second part of the exam involves the use of the speculum, a metal or plastic duck-billed device. The clinician inserts the speculum into the vagina and open its blades to push the vaginal walls apart and get a view of the cervix, the lower part of the uterus that lies at the deep end of the vagina. At this point, samples can be swabbed from the cervix if the woman is due for her Pap test.
The final step is called the bimanual examination. After removing the speculum, the clinician places their index and middle finger into the vagina while using the other hand to press the abdominal organs and feel the size and shape of the uterus and ovaries. Finally, the clinician may do a rectovaginal examination, in which the index finger is placed into the vagina while the middle finger goes into the rectum to feel for any abnormalities.
Until recently, the American College of Obstetricians and Gynecologists (ACOG) recommended that all women ages 21 and older get this exam every year. In 2018, a new guideline from the group proposed that the decision to perform a pelvic exam should be shared between the patient and her doctor. According to ACOG, new studies looking at the impact of routine pelvic examinations on women’s health were unable to show whether the practice benefits women in ways that outsize the negatives, which can include anxiety, discomfort, and unnecessary follow-up procedures, among other things.
For example: While it’s possible during a pelvic exam to detect a case of ovarian cancer in a woman who does not have any symptoms of disease, routine screening has not been found to reduce the overall risk of dying from ovarian cancer.
What’s more, many women find the exam a deeply uncomfortable or even triggering experience. Psychologist Alice Domar, an associate professor at the Beth Israel Deaconess Medical Center at Harvard Medical School, developed a tool in the 1980s to measure women’s anxiety levels before a pelvic exam and to evaluate the cause of any nervousness. “A lot of women were just embarrassed,” she says. “You make yourself very vulnerable, your legs are on stirrups, exposing the most private and vulnerable part of your body.”
New and improved?
The 2018 recommendations are meant to make the gynecological exam more valuable. “ACOG is empowering OB-GYNs to take care of their patients on a case by case basis,’’ says obstetrician-gynecologist Dr. Catherine Cansino, associate professor at the University of California, Davis. Cansino, who is one of the collaborators on the latest guideline, says the new guidance puts a higher emphasis on the woman’s own concerns and health history, rather than adopting a one-size-fits-all approach.
Yet even with the new recommendations, many women are still likely to undergo a pelvic exam on a yearly basis. Performing exams that are not based on evidence may be a matter of culture and routine. “This is what practitioners were taught long ago,” says Dr. George Sawaya, an obstetrician-gynecologist and professor at the University of California, San Francisco. “I think that is probably why there is some reluctance in letting go of the examination.”
Even if the pelvic exam is eliminated from gynecological check-ups (or becomes less frequent), there are still parts of the appointment that will remain, although not every year. For example, unfortunately: the need to use a speculum. The device is currently indispensable for the Pap test, which is still recommended every three years for women age 21 or older, or every five years in combination with HPV testing in women age 30 or older.
About that speculum
Over the 30 years that nurse practitioner Sherry Carter has performed pelvic examinations, she’s witnessed how the process can be an annual source of worry for many women. To make the speculum portion of the exam easier, Carter advises women to ask questions and even request a demonstration of how the speculum works at the start of an appointment.
As for how the exam is conducted, a simple change in the order of things might minimize pain. Carter and her colleagues conducted a clinical trial to test a new pelvic examination technique, which had doctors performing the bimanual examination first and the speculum portion later. According to Carter, this allows the provider to get a tactile assessment of the woman’s anatomy that can inform how to best use the speculum for her body.
Because every woman is different, it can be difficult to find the cervix; not knowing beforehand can mean inserting and removing the speculum several times before getting it right. In Carter’s study, fewer women who received a pelvic examination with the new technique reported pain in comparison to those receiving the traditional exam.
At Duke University, a group of researchers are developing a technology that could potentially turn the speculum into an obsolete apparatus. Their prototype is a slim tubular object with a tampon-inspired design that houses a mini-camera able to capture images of the cervix and transmit them to a mobile phone or a computer.
The technology is being initially tested as a potential substitute for the colposcope, an instrument that helps doctors give a detailed visual examination of the cervix, says researcher Mercy Asiedu, who recently graduated with a PhD from Duke’s Department of Biomedical Engineering. A traditional colposcope — used to investigate the possibility of cervical cancer after an abnormal Pap — has two major limitations: It requires the use of the uncomfortable speculum, and it is expensive.
Duke’s so-called callascope is designed to increase comfort and make cervical cancer screening more accessible, says Asiedu. The researchers are hoping it can also be used to improve the detection of potential infections and to collect cervix samples for the Pap test.
Next, Asiedu and her colleagues aim to create a version that women can use themselves for self-screening, perhaps in their own homes. “My culture emphasizes privacy quite a bit,” says Asiedu, who is from Ghana. “I definitely didn’t go in for cervical cancer screening for a while because I was afraid of the exam and I also had privacy concerns.”
Asiedu went back to Ghana in April 2019 to conduct a study testing the product in a local cervical cancer screening center. “Usually, when patients come in, nurses perform a Pap smear or visual inspection with the naked eye,” she says. “In this case, patients could insert the camera themselves, under the nurses’ guidance, and actually see their cervix on a tablet screen. They realized it wasn’t uncomfortable at all and got really excited about seeing their own cervix.”
At Frog Design, in California, another group of women is working on a project (called the Yona Project) that is rethinking the whole gynecological exam, which includes making the speculum a gentler instrument. Engineer Fran Wang and designer Rachel Hobart say it originated when two members of the group went through a pelvic exam within the same week and started discussing how bad it was. The group’s initial hypothesis was that the speculum was the biggest pain point, says Wang. But it later became clear that the whole experience needed to be reshaped.
The effort to reimagine the process has already resulted in several ideas shared on the group’s website. They go from simple things, such as offering the patient the option to purchase a comfort kit that includes socks to cover her feet in the stirrups, to the development of an app that would offer guided meditation to relax before the exam. They’re also researching ways to make the exam more comfortable and inclusive for the LGBTQ+ population. As for a reimagined speculum, the team says they envision a device that is warmer and quieter, eliminating the nerve-wrecking clicks and snaps of the traditional instrument.
In the meantime, the Yona Project group has heard from at least one clinic that wants to implement one of their ideas: A printed sheet on the examination table showing the patient where her butt should go, eliminating the need to readjust her position after her legs are already spread apart.
“We make recommendations that are incremental, small, that feel accessible and doable to encourage the adoption of tiny changes that can help the patient go through a really challenging exam,” says Hobart.
Yona and Duke’s callascope have one thing in common: Both projects are led by mostly female teams. The Yona Project team says they already feel like they’re breaking through, based on the positive feedback they hear from women who have come across their work. “Over the last course of interviews, we spoke with a patient who revealed they are over 30 and, after reading about Yona, decided they were ready to have their first pelvic exam ever,” says Wang. “To know that we had that kind of impact on even one person has been incredibly powerful.”